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please note this is temporary show for now for skinning as preflight can't have success mail send

Inpatient Referral

For health professionals only

Please complete the following form below or alternatively, you may download the form here and fax it to us.

Required fields are indicated by (*).

Referral information collected will only be used for the purpose of accommodating an admission to a day or inpatient program . This information will not be kept for any other purpose and will not be viewed by any other person than those authorised to do so according to the hospital’s privacy policy.